Diagnostic Accuracy of Endoscopic Ultrasonography in Esophageal Cancer: A Single Center Experience

BACKGROUND/AIMS: Determining the depth of tumor invasion and the presence of regional lymph node metastasis is important in deciding therapeutic strategies. We aimed to evaluate the diagnostic accuracy of EUS in detecting the depth of tumor invasion and regional lymph node metastasis. MATERIALS AND METHODS: A total of 141 consecutive patients underwent preoperative evaluation using EUS, CT, and PET CT from November 2005 to June 2009 in Pusan National University Hospital. We reviewed the patients' medical records and compared EUS and pathologic findings. RESULTS: A total of 59 patients were included in the final analysis. The overall accuracy of EUS in predicting the correct T stage was 79.7% (95% CI, 66.8~88.6%). EUS accurately predicted T stage in 93.2% (95% CI, 82.7~97.8%) of T1 tumors, 79.7% (95% CI, 66.8~88.6%) of T2 tumors, and 86.4% (95% CI, 74.5~93.6%) of T3 tumors. Overall, EUS accurately predicted N stage in 83.1% of cases. EUS correctly predicted N stage in 91.4% of N0 tumors and 70.8% of N1 tumors. CONCLUSIONS: Overall accuracy of EUS for the T and N staging of esophageal cancer was high. Thus, EUS is a useful diagnostic modality in determining the initial stage of esophageal cancer.

Proton Pump Inhibitor Use before Percutaneous Endoscopic Gastrostomy Is Associated with Adverse Outcomes

BACKGROUND/AIMS: Knowledge of the risk factors associated with adverse outcomes after percutaneous endoscopic gastrostomy (PEG) may be helpful for developing PEG recommendations. The purpose of this study was to identify the clinical risk factors associated with adverse clinical outcomes after PEG, especially regarding the use of proton pump inhibitors (PPIs). METHODS: We retrospectively reviewed the data from PEG patients at seven university hospitals between June 2006 and January 2012. All patients were followed up through February 2012 after PEG, and the clinical risk factors for adverse clinical outcomes after PEG were analyzed. RESULTS: Data from 1,021 PEG patients were analyzed. PPI users were more frequently included in the complication group than the noncomplication group (p=0.040). PEG-related complications (p=0.040) and mortality (p=0.003) were more frequent in the PPI group than in the control group. In the subgroup analysis of complicated PEG cases, infectious complications were more frequently found in the PPI group than in the control group (35.8% vs 27.8%). After adjustment for multiple possible confounding factors, PPI users (odds ratio, 1.531; 95% confidence interval, 1.017 to 2.305) and diabetic patients had increased mortality after PEG. CONCLUSIONS: PPI use may be associated with adverse outcomes in patients with PEG; however, further prospective studies investigating this issue are warranted.

A Case of Hepatic Metastasis of Gastric Hepatoid Adenocarcinoma Mistaken for Primary Hepatocellular Carcinoma / 대한소화기학회지

Gastric hepatoid adenocarcinoma is a special type of gastric carcinoma, which produces AFP. We report a case of an metastatic gastric hepatoid adenocarcinoma mistaken for primary hepatocellular carcinoma (HCC). A 72 year-old woman was transferred to our hospital for treatment of the hepatic mass. She underwent subtotal gastrectomy for gastric cancer 2 years ago. A year ago, she was diagnosed with hepatic mass and treated with transhepatic chemoembolization under the suspicion of primary HCC in other hospital. The hepatic mass looked like primary HCC on CT, and serum AFP was elevated to 18,735 IU/mL. We did the transhepatic mass biopsy and compared it to the histology of the previous gastric cancer. The results of immunohistochemical staining between them was coincident, and so it was diagnosed as a hepatic metastasis of gastric hepatoid adenocarcinoma.

A Case of Hepatic Metastasis of Gastric Hepatoid Adenocarcinoma Mistaken for Primary Hepatocellular Carcinoma / 대한소화기학회지

Gastric hepatoid adenocarcinoma is a special type of gastric carcinoma, which produces AFP. We report a case of an metastatic gastric hepatoid adenocarcinoma mistaken for primary hepatocellular carcinoma (HCC). A 72 year-old woman was transferred to our hospital for treatment of the hepatic mass. She underwent subtotal gastrectomy for gastric cancer 2 years ago. A year ago, she was diagnosed with hepatic mass and treated with transhepatic chemoembolization under the suspicion of primary HCC in other hospital. The hepatic mass looked like primary HCC on CT, and serum AFP was elevated to 18,735 IU/mL. We did the transhepatic mass biopsy and compared it to the histology of the previous gastric cancer. The results of immunohistochemical staining between them was coincident, and so it was diagnosed as a hepatic metastasis of gastric hepatoid adenocarcinoma.

A Case of Menetrier's Disease Showing Mucus Bridge Observed during Endoscopy / 대한소화기학회지

Menetrier's disease is a rare entity characterized by large, tortuous gastric mucosal folds. The mucosal folds in Menetrier's disease are often most prominent in the body and fundus. Histologically, massive foveolar hyperplasia (hyperplasia of surface and glandular mucous cells) is noted, which replaces most of the chief and parietal cells. Profuse mucus is usually observed during the endoscopy but there have been few cases that show interesting endoscopic findings such as mucus bridge or water pearl. Herein, we report a case of Menetrier's disease showing mucus bridge by excessive mucus observed during the endoscopy.

A Case of Gallstone Ileus Treated with Electrohydraulic Lithotripsy Guided by Colonoscopy / 대한소화기학회지

A 63-year-old woman was admitted to the hospital with abdominal pain and nausea. Her abdomen was distended with obstructive bowel sounds on exam. There was diffuse abdominal tenderness but no palpable masses. Abdominal computed tomography (CT) scan revealed a large gallstone in the ileum. Surgical intervention was deferred given patient's known significant liver cirrhosis (Child-Pugh class B). Instead colonoscopy was performed and a large gallstone was found to be impacted at the ileocecal valve. The gallstone was fragmented using electrohydraulic lithotripsy (EHL) and then retrieved with snare and forceps. The patient made a full recovery and was eventually discharged home. This is the first reported case of an impacted gallstone at the ileocecal valve with successful colonoscopic treatment using electrohydraulic lithotripsy in Korea. This case highlights the potential therapeutic benefits for colonscopic retrieval of a gallstone impacted at the ileocecal valve in well selected individuals.

Characteristics of Laterally Spreading Colorectal Tumors according to Morphologic Classifications / 대한소화기내시경학회지

BACKGROUND/AIMS: Laterally spreading tumors (LSTs) are similar in color to the adjacent mucosa, so they are difficult to recognize. This study aimed to investigate the features of LSTs by morphologic classification and find effective diagnoses and treatments. METHODS: This retrospective study was done between March 2006 and August 2008. We reviewed patients' medical records, endoscopic findings, and histological findings. RESULTS: A total of 151 patients met criteria for LSTs. Eighty-seven lesions (57.6%) were of the granular type. The most frequent location was ascending colon (37.1%), followed by rectum and sigmoid colon (36.4%). The cecum is a common site in the granular type, but the transverse colon is common in the nongranular type. The overall malignancy rate was 21.2%, and the malignant rate increased in proportion to size. Malignant rates were higher for the mixed nodular type (25.9%) and pseudo-depressed type (41.2%) than for the homogeneous granular type (3.0%) or flat elevated type (10.0%). CONCLUSIONS: LSTs showed different clinicopathologic characteristics according to their morphologic classification. The homogenous type has a lower malignant potential. Piecemeal resection for those with a large diameter is possible, while the pseudo-depressed and mixed nodular types have a higher malignant potential and should receive en-bloc resection as soon as possible.

2 Cases of Gastric Mucosa-associated Lymphoid Tissue Lymphoma Presenting as a Submucosal Tumor-like Lesion / 대한소화기학회지

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is the most common form of primary extranodal lymphomas. In most cases, it is developed as multifocal and mucosal lesions, and its initial diagnosis is made by biopsy of suspicious lesions on endoscopy. However, when gastric MALT lymphoma afflict submucosal site without typical mucosal lesion, further procedures are necessary for diagnosis, such as endoscopic mucosal resection and endoscopic ultrasonography. We recently experienced two cases of submucosal tumor-like gastric MALT lymphoma. Both cases were without any mucosal lesion. One case was confirmed by endoscopic mucosal resection, and the latter was by wedge resection. Treatment modalities included endoscopic mucosal resection, surgery, H. pylori eradication, and/or chemotherapy. Both cases achieved complete remission until our 18 months' and 16 months' follow up.

Combined Dual Channel Impedance/pH-metry in Patients With Suspected Laryngopharyngeal Reflux

BACKGROUND/AIMS: Laryngopharyngeal symptoms of gastroesophageal reflux disease (GERD) such as globus sensation, hoarseness and chronic cough are becoming increasingly recognized. This study was aimed to investigate the diagnostic usefulness of combined dual channel multichannel intraluminal impedance (MII)/pH-metry in 'off-proton pump inhibitor (PPI)' patients with suspected laryngopharyngeal reflux. METHODS: Ninety-eight patients with laryngopharyngeal symptoms of GERD were included. All patients were 'off-PPI' state for at least 2 weeks prior to the study, and underwent endoscopy and dual channel combined MII/pH-metry. RESULTS: The mean age of the patients was 49.8 +/- 10.9 years and there were 44 males (44.9%). Fifty-three patients (54.1%) showed pathologic gastroesophageal reflux (GER). Combined dual channel MII/pH-metry achieved highest diagnostic yield of 49.0% and diagnostic yield of single channel combined MII/pH-metry was 37.8%. Addition of MII to standard pH-metry increased twofold of the diagnostic yield for detecting GER. Among 37 patients (37.8%) who had pathologic GER being detected by MII/pH-metry, 19 patients (19.4%) had nonacid GER (nonacid GER group) while 18 patients (18.4%) had acid GER (acid GER group). Pathologic GER group, as classified by MII/pH-metry showed more frequent globus sensation than nonpathologic GER group. Acid GER group had more proximal reflux than nonacid GER group, especially in the upright position. CONCLUSIONS: In this study, combined dual channel MII/pH-metry showed the highest diagnostic yield for detecting GER. This technique can be performed primarily to accurately diagnose laryngopharyngeal reflux disease and exclude other causes of laryngopharyngeal symptoms.

The Usefulness of In Vitro Interferon-gamma Assay for Differential Diagnosis between Intestinal Tuberculosis and Crohn's Disease / 대한소화기학회지

BACKGROUND/AIMS: It is difficult to clinically and endoscopically differentiate intestinal tuberculosis (ITB) and Crohn's disease (CD). The aim of this study was to evaluate the usefulness of in vitro interferon-gamma (INF-gamma) assay for differential diagnosis between ITB and CD. METHODS: Sixty patients for whom differential diagnosis between ITB and CD was difficult were enrolled between January 2007 and January 2009. The INF-gamma-producing T-cell response to early secreted antigenic target 6 and culture filtrate protein 10 were measured by T-SPOT.TB blood test in vitro. We evaluated the usefulness of T-SPOT.TB blood test by comparing its results with the final diagnosis. RESULTS: Twenty and forty patients were revealed to be positive and negative in T-SPOT.TB blood test, respectively. Of the 20 patients found to be positive, 12 patients (60%) were finally diagnosed as ITB, 6 patients as CD, and 2 patients as Behcet's enterocolitis. Of the 40 patients with negative results, 38 patients (95%) were diagnosed as CD; one as Behcet's enterocolitis; one as nonspecific colitis; none as ITB. The sensitivity and specificity of T-SPOT.TB blood test for ITB were 100% and 83.3%, respectively. Positive and negative predictive values of T-SPOT.TB blood test for ITB were 60.0% and 100%, respectively. CONCLUSIONS: When differential diagnosis between ITB and CD is difficult, T-SPOT.TB blood test may be a helpful and rapid diagnostic tool to exclude ITB. Prospective large-scaled studies are required for further evaluation of the usefulness of T-SPOT.TB blood test for differential diagnosis between ITB and CD.

Clinical Characteristics of 17 Cases of Eosinophilic Gastroenteritis / 대한소화기학회지

No abstract available.

Hemobilia as the Initial Manifestation of Cholangiocarcinoma in a Patient with Choledochoduodenostomy / 대한소화기학회지

Hemobilia occurs when injury or disease causes communication between intrahepatic blood vessels and the intrahepatic or extrahepatic biliary system. The causes of hemobilia include trauma, gallstone disease, vascular malformation, inflammation, and biliary or hepatic tumors. Hemobilia could be diagnosed by endoscopy, hepatic angiography, computed tomography, and ultrasonogram. Patients with hemobilia may present with biliary colic, obstructive jaundice and gastrointestinal bleeding. Extrahepatic cholangiocarcinoma usually presents with obstructive jaundice and is one of the unusual cause of hemobilia. We, herein, report a case of hemobilia caused by cholangiocarcinoma in a 69-year-old woman. She had the past history of lung cancer and choledochoduodenostomy due to gallstone. Esophagogastroduodenoscopy revealed a blood clot protruding from the choledochoduodenostomy site and the ulcerative mass in the common bile duct. Pathologic examination of the ulcerative mass was compatible with those of cholangiocarcinoma.

Clinical and Endoscopic Characteristics of Acute Hemorrhagic Rectal Ulcer and the Risk Factor of Rebleeding

BACKGROUND/AIMS: Acute hemorrhagic rectal ulcers (AHRUs) are rare and have not been thoroughly studied. This study aimed to assess the clinical and endoscopic characteristics of AHRUs and to determine the risk factors for rebleeding after the initial management. METHODS: Thirty patients who underwent colonoscopy within 48 hours of the onset of hematochezia were consecutively enrolled between January 2004 and December 2007. The patients were divided into a rebleeding group and a non-rebleeding group according to presence of recurrent bleeding after initial management. We analyzed the clinical features, including the underlying disorder, the Karnofsky performance status (PS), the use of anticoagulant or antiplatelet agents, the endoscopic findings, and the methods used for hemostasis. RESULTS: All of the patients were elderly, in a bedridden status, and all had experienced the sudden onset of massive, fresh rectal bleeding without pain. The characteristics of the lesions on colonoscopy included solitary or multiple rectal ulcers, or Dieulafoy lesions located in the distal rectum. There were no differences between the two groups based on mean age, gender, use of anticoagulant or antiplatelet agents, PS, methods of hemostasis, and clinical outcomes. The PT (INR) and endoscopic findings (Dieulafoy types), however, differed significantly between the two groups (p=0.024 and p=0.013, respectively). CONCLUSIONS: When massive hematochezia occurs in bedridden patients with severe comorbid illnesses, AHRUs should be considered in the differential diagnosis. It is advisable to be vigilant for rebleeding in patients with prolongation of the PT (INR) and Dieulafoy-type ulcers on colonoscopy.

A Case of Rectal Schwannoma Presenting with Hematochezia / 대한소화기학회지

Rectal schwannoma is a rare mesenchymal tumor originating from Schwann's cell. We experienced a 61- year-old female patient who complained of blood tinged and narrow calibered stool for several years, and found a 4 cm sized submucosal tumor with a central ulcer on the rectal wall during colonoscopy. She underwent transanal excision. Microscopically, the tumor was composed of fasciculating bundles of spindle cells with benign nuclear atypia and peripheral lymphoid cell cuffing. Tumor cells showed a diffuse strong immunoreactivity to S-100 protein, but not stain for CD 34, desmin and smooth muscle actin. This is the first case report of rectal schwannoma in Korea.

A Case of Primary Angiosarcoma of Small Intestine Presenting as Recurrent Gastrointestinal Bleeding / 대한소화기학회지

Angiosarcoma is a rare malignant tumor which occurs frequently in the skin and soft subcutis. Moreover, primary gastrointestinal angiosarcomas are very rare. This tumor manifests as non-specific symptoms such as gastrointestinal bleeding, abdominal pain and nausea. The diagnosis is often made at an advanced stage. Surgery, chemotherapy and radiotherapy are the mainstay of treatment. However, the prognosis is very poor. We report a case of primary angiosarcoma of the small intestine presenting as recurrent gastrointestinal bleeding. A 54-year-old man was admitted with recurrent gastrointestinal bleeding. An abdominal CT scan revealed an ileo-ileal intussusception. Segmental resection was performed with ileo-ileal anastomosis. The ileal mass was diagnosed as angiosarcoma on immunohistochemical stain. He received 3 cycles of chemotherapy, but died 5 months after the diagnosis.

A Case of Gastric Metastasis of Breast Carcinoma Resembling Early Gastric Cancer / 대한소화기학회지

Many patients suffering from breast carcinoma have metastases at initial diagnosis. The common metastatic sites are skeleton, liver and lung. Metastases to stomach are rare and only three cases have been reported in Korea. The endoscopic features of gastric metastases from breast carcinoma can be divided into three main categories: diffuse infiltration, external compression, and localized tumor deposition with ulceration or with a polypoid mass. However, metastatic gastric lesions which resemble early gastric carcinoma are rare. Typically, gastric metastases are confined to submucosa and muscularis, so that mucosal biopsy specimens might be false-negative. We report a case of gastric metastasis from infiltrative lobular carcinoma of the breast in a 66-year-old woman who had undergone left mastectomy with postoperative radiotherapy 17 years earlier. Initial diagnosis was early gastric carcinoma, signet ring cell type on gastric biopsy findings. However, definitive diagnosis of metastatic breast cancer was confirmed after endoscopic mucosal resection of a presumed primary early gastric carcinoma.

A Case of Respiratory Failure Caused by Gastropleural Fistula: A Case Report / 대한구급학회지

Gastropleural fistula is a very rare disorder, caused by various conditions, such as trauma and postoperative complication, subphrenic abscess, malignancy, hiatal hernia. The major causes of the gastropleural fistula have changed from trauma and subphrenic abscess to postoperative complication of malignant disorders. We report a case of empyema that developed respiratory failure caused by gastropleural fistula in a middle age woman with review of related articles.

A Case of Acute Pancreatitis Caused by Santorinicele with Incomplete Pancreas Divisum / 대한소화기내시경학회지

A focal cystic dilatation of the terminal portion of the dorsal pancreatic duct at the minor papilla, termed "santorinicele", is seen in a small number of patients with pancreas divisum. Santorinicele is believed to result from a combination, either acquired or congenital, of relative obstruction and weakness of the distal ductal wall and has been suggested as a possible cause of relative stenosis of the accessory papilla, a risk factor for pancreatitis. We report a case of santorinicele associated with incomplete pancreas divisum, found in a 68-year-old woman presented with acute pancreatitis with a brief review of the literatures.